- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $112.20 / $204.17
| Professional | | $107.15 | $112.20 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.67 / $45.71 / $181.97
| Professional | | $34.67 | $45.71 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.13 / $165.96 / $316.23
| Professional | | $89.13 | $165.96 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $173.78 / $199.53
| Professional | | $158.49 | $173.78 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.69 / $72.44 / $223.87
| Professional | | $41.69 | $72.44 | $223.87 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $173.78 / $229.09
| Professional | | $97.72 | $173.78 | $229.09 |